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Chapter 8 Care Coordination

Care Coordination in U.S. Healthcare Care coordination has in recent years emerged as one of the most rapidly expanding areas of nursing practice. Seen as a foundational element of healthcare reform, much attention has been directed toward defining and measuring specific processes and quality outcomes related to care coordination (Bower, 2016; Swan et al., 2019b). Government agencies, health systems, insurers, and quality programs across the United States are focused on improving care and reducing costs, particularly for high-risk and vulnerable populations that consume healthcare resources. There is an urgency within the healthcare community to make progress in this rap idly evolving area of nursing care. Healthcare services in the United States are among the most expensive in the world, yet the quality of care has been negatively impacted by increasing complexity, decentralization, frag mentation of services, and failure to engage individuals and families in their care. Individuals often see multiple providers and receive a variety of services with rapid turnover, leading to confusion and difficulty managing complex plans of care. These factors ultimately affect health outcomes. Care coordination has been recognized as a key strategy for addressing these issues, and registered nurses (RNs) are well positioned to lead this initiative. Historical Perspective Although the awareness of nursing’s significant contributions to care coordination in health care may be recent, RNs have, in fact, been providing care coordination for decades with little recognition of the processes inherent in the provision and organization of these services. In recent history, this began with the advent of diagnosis-related groups (DRGs) in the 1980s and managed care in the 1990s. At that time, health plans began to require primary care “gatekeep ers” to oversee access to expensive specialist care. Care management evolved as a way for hospitals to control cost and reduce length of stay. RNs were deployed as case managers, both by hospitals and in community settings, where they followed high-risk individuals in an effort to reduce costs and prevent readmission. Health plans created utilization management roles to audit hospital care and coordinate postdischarge services (Zazworsky & Bower, 2016). These payer-driven changes in care delivery increased the visibility of and payment for specific treatments and interventions. One downstream effect of these changes was that care coordination activities that may be wide-ranging and difficult to ascribe to a single diagnosis became increasingly critical, yet often unrecognized and undervalued. This attention to cost and quality in healthcare provided the foundation for today’s focus on RN care coordination. Readers are referred to Chapter 2 for a full discussion of national strategies and payment mod els driving the need for care coordination. Nursing Perspective In 2012, the American Academy of Nursing (AAN) put forth policy recommendations to the Centers for Medicare and Medicaid Services (CMS), urging them to move quickly to adopt clear and consistent definitions for care coordination and transitional care and to implement reimbursement models for these services at the community level. Further, the AAN recom mended that such models be sustainable and replicable. The policy statement urged the gov ernment to allocate funding for the development of performance measures and information technology to ensure consistent outcome measurement. Finally, they recommended that the government invest in workforce development directly related to care coordination and transi tion services (Cipriano, 2012). In 2013, AAN published the American Nurses Association’s (ANA’s) white paper, The Value of Nursing Care Coordination , highlighting the numerous accomplishments of the profession of nursing in promoting, practicing, and leading care coordination in diverse settings and on behalf of a wide variety of individual populations.

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